Perineal hernia repair with acellular dermal graft and suture anchor fixation.

Perineal hernia is an infrequent complication of abdominoperineal resection, but can be problematic. Multiple surgical approaches to the repair of perineal hernia have been described, including abdominal, perineal, and combined methods; most feature the use of a prosthetic mesh. We report a case wherein a large perineal hernia was reduced via an abdominal approach, and then repaired by the placement of an acellular dermal graft (DermaMatrix) fixated anteriorly directly to the pubis with Mitek suture anchors.

The presence of colorectal hepatic metastases does not preclude pulmonary metastasectomy.

Hepatic metastases due to colorectal carcinoma have often been felt to preclude pulmonary metastasectomy. With the recent advances in surgical options, should patients with both liver and lung metastases be considered for surgical resection? The current study reviews the impact of such aggressive management on disease-free and overall survival (OS). The clinical course of 63 patients presenting with colorectal metastasis to the lung alone (group 1, n = 45) or combined hepatic and lung metastases (group 2, n = 18) were reviewed. All patients underwent complete resection of their lung metastases. Surgical control of hepatic tumor burden was achieved by tumor ablation, intra-arterial therapy, and/or resection. All patients in group 1 and group 2 were available for a mean follow-up of 27 and 24 months, respectively. The presence of hepatic metastases, the resectability of hepatic tumor burden, and the disease-free interval after pulmonary metastasectomy did not significantly influence survival. These findings demonstrate that aggressive surgical management of pulmonary metastases in the presence of liver metastases offers a similar benefit as compared to patients with pulmonary metastases alone. Therefore, hepatic metastatic disease does not preclude an attempt at pulmonary metastasectomy if hepatic metastases can be resected or remains responsive to therapy. Such an approach achieves comparable OS and mean survival when compared to pulmonary metastasectomy alone.

Rectal pulse granuloma.

Pulse granuloma is a rare benign entity, most likely representing a foreign body reaction to vegetable particles. We report a case of a pulse granuloma involving the rectum. The patient presented with a submucosal and intramuscular mass lesion found at routine rectal examination and subsequent colonoscopy. The mass was excised and the microscopic examination revealed acute and chronic inflammatory cells, foreign-body giant cells, vegetable matter, and convoluted hyaline rings and scattered circular structures containing basophilic granules, consistent with pulse granuloma. There are a few reports in the literature of pulse granulomas, with most occurring in the oral cavity or lungs. To the best of our knowledge, this is the first reported example of pulse granuloma in the rectum. Although rare, familiarity with this entity's distinctive histopathologic features may avoid a delay in diagnosis and prevent the expense of distinguishing it from its histologic lookalikes.

Hand-assisted laparoscopic surgery (HALS) with the HandPort system: initial experience with 68 patients.

OBJECTIVE: To evaluate the feasibility and potential benefits of hand-assisted laparoscopic surgery with the HandPort System, a new device. SUMMARY BACKGROUND DATA: In hand-assisted laparoscopic surgery, the surgeon inserts a hand into the abdomen while pneumoperitoneum is maintained. The hand assists laparoscopic instruments and is helpful in complex laparoscopic cases. METHODS: A prospective nonrandomized study was initiated with the participation of 10 laparoscopic surgical centers. Surgeons were free to test the device in any situation where they expected a potential advantage over conventional laparoscopy. RESULTS: Sixty-eight patients were entered in the study. Operations included colorectal procedures (sigmoidectomy, right colectomy, resection rectopexy), splenectomy for splenomegaly, living-related donor nephrectomy, gastric banding for morbid obesity, partial gastrectomy, and various other procedures. Mean incision size for the HandPort was 7.4 cm. Most surgeons (78%) preferred to insert their nondominant hand into the abdomen. Pneumoperitoneum was generally maintained at 14 mmHg, and only one patient required conversion to open surgery as a result of an unmanageable air leak. Hand fatigue during surgery was noted in 20.6%. CONCLUSIONS: The hand-assisted technique appeared to be useful in minimally invasive colorectal surgery, splenectomy for splenomegaly, living-related donor nephrectomy, and procedures considered too complex for a laparoscopic approach. This approach provides excellent means to explore, to retract safely, and to apply immediate hemostasis when needed. Although the data presented here reflect the authors' initial experience, they compare favorably with series of similar procedures performed purely laparoscopically.

Hemorrhoids, anal fissure, and carcinoma of the colon, rectum, and anus during pregnancy.

The pregnant patient afflicted with a variety of colorectal conditions merits special consideration for reasons related to the safety and timeliness of operation while preserving fetal viability and fertility. The literature is scanty with respect to hemorrhoids, fissures, and colorectal and anal carcinoma. Therefore, the patient has to have a forthright discussion with her physician(s) about the pros and cons of operative and nonoperative approaches, which can result in either therapeutic abortion and timely surgery versus preserving the fetus and taking on the unknown factor of whether delay in treatment will cause an adverse outcome. This underscores the need for a frank discussion with the patient with regard to anticipated outcomes. In benign conditions, there is more latitude to adopt a conservative approach, as the patient's ability to tolerate the symptoms of her condition would dictate the need for definitive operative therapy. In the patient with malignancy, delaying surgical or radiation therapy carries an unknown risk to the patient. Here, the patient's personal views regarding abortion and future fertility dictate the timing of definitive treatment.

Pathogenesis of pancreatic sepsis.

Although pancreatic sepsis is the most common cause of major morbidity and mortality associated with acute pancreatitis, the pathogenesis of such infections is unknown. Since intraperitoneal foci of inflammation are known to promote bacterial translocation, we hypothesized that acute pancreatitis promotes bacterial translocation that leads to infection of the inflamed pancreas and peripancreatic tissues. Non-lethal acute pancreatitis was induced in rats, and the translocation of live bacteria to the pancreas, mesenteric lymph nodes, liver, and spleen was determined. The presence of orally fed fluorescent beads, sensitive inert markers of translocation, was also determined in the pancreas and mesenteric lymph nodes. Live bacteria were recovered from 33% of the pancreata of rats with acute pancreatitis but from none of the control rats. Beads were visualized in 91% of the pancreata of rats with acute pancreatitis but in none of the pancreata from control rats. Beads were not visualized in the mesenteric lymph nodes of rats with acute pancreatitis, suggesting a transperitoneal route of migration. We conclude that acute pancreatitis promotes bacterial translocation leading to transperitoneal infection of the pancreas. These results support the use of selective decontamination of the gut and peritoneal lavage for the prevention of pancreatic infections in acute pancreatitis.

Laparotomy for fulminant pseudomembranous colitis.

Clostridium difficile-associated pseudomembranous colitis is an increasingly common nosocomial infection that usually responds to oral antibiotics. Presentation as an acute abdomen occurred in 12 patients, leading to 14 laparotomies. A distinctive clinical picture was observed: advanced age, recent treatment with antibiotics, fever, abdominal pain, tenderness, marked leukocytosis, and ileus. Only six of the 12 patients had diarrhea. Five were immunosuppressed. Abdominal computed tomographic scans revealed ascites and a massively thickened colonic wall. All four patients treated by subtotal colectomy survived. Four of 10 patients treated only with laparotomy or segmental colectomy died, four responded to medical therapy, and the conditions of two deteriorated but were salvaged by subtotal colectomy. Early diagnosis via endoscopy or computed tomography should obviate the need for exploratory operations. However, progressive toxic effects indicate failure of medical therapy and the need for subtotal colectomy.